THE ABDOMINAL COCOON SYNDROME: A CASE REPORT O. Abana MD, S. Rashid MD, B Blancher, K Sulaiman MD Department of Internal Medicine, LSUHSC Shreveport, Louisiana
INTRODUCTION: Encapsulating peritoneal sclerosis (EPS) is themost devastating complication of peritoneal dialysis. While recurrent bacterial peritonitis has been strongly linked, EPS secondary to fungal peritonitis is a lot less common.
CASE: A 19 year-old woman with Type 1 DM, Nephropathic Cystinosis and ESRD was admitted with a two-week history of progressive abdominal distension associatedwithnausea and vomiting. She hadbeenonperitoneal dialysis (PD) for 14 years but was switched to hemodialysis (HD) 3 months prior to current presentation due to complications of fungal peritonitis (cultures positive for C. parapsilosis). She had been discharged on oral antifungal agents but stopped taking them after just 2 weeks. Physical exam was unremarkable except for a soft, distended abdomen with normoactive bowel sounds. Laboratory tests showed WBC elevated at 17,000 and Hb decreased at 7.2g/dl. KUB showed diffuse peritoneal calcifications and contrasted CT abdomen showed abdominal cocooning consistent with encapsulating peritoneal sclerosis. Blood and urine cultures showed no antimicrobial growth but ascitic fluid grew Candida parapsilosis. She received a prolonged course of intravenous micafungin based on sensitivities with plan for possible surgical and/or immunosuppressive therapy for EPS following treatment of fungal peritonitis. DISCUSSION: EPS is a devastating but rare complication of long-term PD. Extensive thickening and fibrosis of the peritoneum results in the formation of a fibrous cocoon encapsulating the bowel leading to intestinal obstruction, strangulation and perforation. Since the duration of time on PD (particularly after five or more years) is a major risk factor, some have advocated a time limit for PD. However, the vast majority of patients on PD do not develop EPS, and the potential benefit of pre-emptively stopping peritoneal dialysis is offset by the risks associated with HD. EPS has also been shown to present after withdrawal from PD in most patients and EPS can develop up to 5 years after cessation of PD. Other risk factors include multiple episodes of severe peritonitis, younger age at initiation of PD, higher concentration of dialysate fluids and certain drugs such as beta blockers.
19
Made with FlippingBook Digital Publishing Software